FAQs

Certification

Yes! ACDIS Members can earn 10 free CEUs each year. Take the quiz with each edition of CDI Journal quiz (published six times a year) and earn one CEU per edition. Participate in the ACDIS quarterly conference calls and earn one CEU for compelting the accompanying survey. To read more about earning CCDS CEUs, click here.

To learn more about CCDS recertification, watch this video with CCDS Coordinator Penny Richards.

Allows the organization to identify those individuals who have demonstrated knowledge and skills that equip them to manage and run an effective clinical documentation program

Demonstrates that individuals are competent to provide ongoing education for physicians and other clinical staff

Ensures the maintenance of professional standards through the individuals’ commitment to continuing education to maintain certification and stay up-to-date on regulations and areas that are critical to accurate documentation, coding, and hospital quality initiatives

Provides the organization with peace of mind in knowing that, in an atmosphere of increased government scrutiny, compliance standards are met due to adherence with the ACDIS Code of Ethics

Benefits for the Clinical Documentation Specialist:

Encourages clinical documentation specialists to hold themselves to a higher standard and obtain the requisite knowledge and skills to fulfill their responsibilities effectively

Denotes that clinical documentation specialists have achieved a mark of distinction based on an acquired body of knowledge, skills, and experience

Establishes leadership within their profession and provide physicians and clinical staff with education regarding documentation requirements

Emphasizes the role of the clinical documentation specialist within the health information management (HIM) arena and establishes the clinical documentation specialist profession as key in ensuring healthcare data integrity

Encourages continued education to keep pace with changing government and private payer regulations and industry standards

The Association of Clinical Documentation Improvement Specialists (ACDIS) contracts with Applied Measurement Professionals, Inc., (AMP) to provide management and examination services. AMP provides administrative support for the certification process, including examination development, validation, and administration. AMP carefully adheres to industry standards for development of practice-related, criterion-referenced examinations to assess competency.

ACDIS maintains all CCD program records, handles finances, and processes examination and re-examination applications, and the recertification processes, including requests for continuing education approval.

To learn more about scheduling your CCDS exam with AMP, watch this video with CCDS Coordinator Penny Richards.

The examination content is based on analysis of the activities of clinical documentation specialists in a wide range of settings, hospital sizes, and circumstances. Input from a survey taken by members of the Association of Clinical Documentation Improvement Specialists (ACDIS), and the input and research of an advisory board comprised of experienced clinical documentation specialists, was used to identify seven core competencies with which clinical documentation specialists should have a strong working knowledge.

The examination is an objective, multiple-choice test consisting of 140 questions. The examination questions are designed to test the candidate's multidisciplinary knowledge of clinical, coding, and healthcare regulations, as well as the roles and responsibilities of a clinical documentation specialist. The questions are updated on a continuous basis to keep them relevant to current realities in healthcare. Choices of answers to the examination questions will be identified as A, B, C, or D.

Recall questions test the candidate's knowledge of specific facts and concepts relevant to the day-to-day work of clinical documentation professionals.

Application questions require the candidate to interpret or apply information, guidelines, or rules to a particular situation.

Analysis questions test the candidate's ability to evaluate and integrate a range of information in problem solving to address a particular challenge.

The current examination is designed so that approximately 40% of the questions will be of the recall type, 40% of the application type, and 20% of the analysis type.

To learn more about the exam day, watch this video with CCDS Coordinator Penny Richards.

To become a Certified Clinical Documentation Specialist (CCDS), a candidate must pass the examination. It is offered by computer at more than 200 AMP Assessment Centers located around the country (visit www.goamp.com and follow the links to find locations and directions).

Candidates who apply to take the examination will be contacted when they have been approved to take the examination.

Candidates have four months/120 days from the date their name is submitted to AMP, the examination testing company, to schedule and take their examination.

There are no application deadlines (except for the examination given at the conference) and a candidate who meets eligibility requirements may submit an application and fee at any time. The fee will not be processed until the application is approved.

Allows the organization to identify those individuals who have demonstrated knowledge and skills that equip them to manage and run an effective clinical documentation program

Demonstrates that individuals are competent to provide ongoing education for physicians and other clinical staff

Ensures the maintenance of professional standards through the individuals’ commitment to continuing education to maintain certification and stay up-to-date on regulations and areas that are critical to accurate documentation, coding, and hospital quality initiatives

Provides the organization with peace of mind in knowing that, in an atmosphere of increased government scrutiny, compliance standards are met due to adherence with the ACDIS Code of Ethics

Benefits for the Clinical Documentation Specialist:

Encourages clinical documentation specialists to hold themselves to a higher standard and obtain the requisite knowledge and skills to fulfill their responsibilities effectively

Denotes that clinical documentation specialists have achieved a mark of distinction based on an acquired body of knowledge, skills, and experience

Establishes leadership within their profession and provide physicians and clinical staff with education regarding documentation requirements

Emphasizes the role of the clinical documentation specialist within the health information management (HIM) arena and establishes the clinical documentation specialist profession as key in ensuring healthcare data integrity

Encourages continued education to keep pace with changing government and private payer regulations and industry standards

Candidates for the Certified Clinical Documentation Specialist (CCDS) designation must meet educational and work experience requirements. To read a complete breakdown of the requirements, download the Exam Candidate's Handbook by clicking here. To download a quick reference flowchart, click here.

The candidate for the CCDS exam will meet one of the following three education and experience standards and currently be employed as either a concurrent or retrospective Clinical Documentation Specialist:

An RN, RHIA, RHIT, MD, or DO and two (2) years of experience as a concurrent/retrospective documentation specialist in an inpatient acute care facility using the United States IPPS system.

An Associate’s degree (or equivalent) in an allied health field (other than what is listed above) and three (3) years of experience as a concurrent/retrospective documentation specialist in an inpatient acute care facility using the United States IPPS system. The education component must include completed college-level course work in medical terminology and human anatomy and physiology.

Formal education (accredited college-level course work) in medical terminology, human anatomy and physiology, and disease process, or the AHIMA CCS credential, and a minimum of three (3) years of experience in the role as a concurrent/retrospective documentation specialist in an inpatient acute care facility using the United States IPPS system.

*Years of experience is defined as full time employment or greater than 2,000 hours/year

What is a concurrent documentation specialist?

The concurrent documentation specialist:

Reviews medical records daily and in the current time, while the patient is hospitalized

Works collaboratively using real-time conversation with physicians and medical team members caring for the patient

Uses his or her clinical knowledge to evaluate how the medical record will translate into coded data, including reviewing provider and other clinical documentation, lab results, diagnostic information, and treatment plans

Communicates with providers, whether in verbal discussion or by query, for missing, unclear, or conflicting documentation

Understands complications, comorbidities, severity of illness, risk of mortality, case mix, and the impact of procedures on the billed record, and shares this knowledge with providers and members of the healthcare team

What is a retrospective documentation specialist?

The retrospective documentation specialist:

Daily reviews medical records of post discharge, pre-bill records

Works collaboratively using real-time conversation with physicians and medical team members who cared for the patient

Uses his or her clinical knowledge to evaluate how the medical record will translate into coded data, including reviewing provider and other clinical documentation, lab results, diagnostic information, and treatment plans

Communicates with providers, whether in verbal discussion or by query, for missing, unclear, or conflicting documentation

Understands complications, comorbidities, severity of illness, risk of mortality, case mix, and the impact of procedures on the billed record, and shares this knowledge with providers and members of the healthcare team

Equivalent foreign medical graduate experience documenting in a medical record as a clinician or resident does not meet the experience requirement.

To learn more about your CCDS first steps, watch this video with CCDS Coordinator Penny Richards.

Membership

ACDIS is a community that welcomes idea sharing, networking, creative problem solving, and free and open speech and debate. As a result, we publish many papers, articles, news briefs, and informal commentary across our website. The question some members ask is: What articles represent ACDIS’ official stance, guidance, or advice on a particular question or issue?

To answer this question, we have established a “Hierarchy of Authority” detailing which articles are considered official ACDIS advice or guidance, and which are not. The most authoritative “ACDIS endorsed” publications are listed first.

1. ACDIS Position Papers: ACDIS Position Papers are the association’s official, consensus stance on an issue. ACDIS Position Papers set a recommended standard for the CDI industry to follow. They advocate on behalf of a certain position or offer concrete solutions for a particular problem. All current members of the ACDIS Advisory Board must review/approve a Position Paper and are encouraged to materially contribute to its creation. You can find ACDIS Position Papers here: https://acdis.org/resources?type=12

2. ACDIS White Papers: White Papers are next in the ACDIS hierarchy of authority. An ACDIS white paper discusses CDI best practice, advances new ideas, increases knowledge, or offers suggestions for administrative simplification. These can be written by a single ACDIS Advisory Board member, a smaller subset of the board, or can be written by external sources (when they are, they are clearly labelled as such). White Papers are less formal than a Position Paper but are peer-reviewed. You can find ACDIS White Papers here: https://acdis.org/resources?type=14

3. CDI Journal: Articles in our bi-monthly members-only CDI Journal are subject to editorial review and extensive editing prior to publication. But unless otherwise noted they do not represent official ACDIS recommendation or policy. ACDIS’ CDI Journal strives to use a variety of sources in its articles to ensure fair and accurate coverage. Occasionally the CDI Journal publishes opinion pieces and columns from industry experts. We strive to clearly mark these as such, and advice provided is general in nature and CDI staff should review the information to ensure compliance. While ACDIS Advisory Board members frequently write articles for CDI Journal the opinions expressed represent their own, not those of the association. You can find current and archived issues of CDI Journal here: https://acdis.org/articles/archive?publication=1

4.CDI Strategies: Unless otherwise noted CDI Strategies articles are summations of relevant news articles, recaps of local chapter activity, notifications of articles or downloads to the ACDIS website, or Q&As with industry representatives. These are curated, edited, and uploaded by ACDIS editorial staff but not peer-reviewed. You can find an archive of CDI Strategies articles here: https://acdis.org/articles/archive?publication=2

5. Forum posts, comments, and social media: Posts in ACDIS Forum, comments appended to the end of articles (via our Disqus plug-in) or on ACDIS Blog, and posts or replies to ACDIS social media platforms including Facebook, Instagram, and Twitter, are automatically assumed to be the opinions of the person posting the comment. Inappropriate or offensive posts will be removed.

To sum up, unless an article is a Position Paper, or an ACDIS White Paper (i.e., a White Paper written or approved by the ACDIS advisory board, not from an outside source), it is not considered official ACDIS guidance.

General note regarding articles on this website

Please note that ACDIS is an association of professionals governed by an elected advisory board and administrators. It is not a regulatory body. As in all matters, please refer to your manager, compliance department, and/or legal counsel before implementing changes or altering your organization’s policies and procedures.

Does ACDIS Radio offer CCDS or other CEUs, or does it offer materials or other handouts to listeners?

No, ACDIS Radio is a short, 30 minute, informal program that is conversational in nature and as such is not suitable for CEUs. No materials are provided in advance. From time to time speakers will supply .ppt slides or other materials, and if they do these are typically posted in the ACDIS Radio archives beneath the show recording.

The quizzes for the bi-monthly CDI Journal can be accessed in the article list on the CDI Journal page. Go to the last page of the article listings for that issue to locate the quiz. We also provide a link to the quiz in the "Download Full Issue" page for each issue.